The journey inward

It is difficult at best to attempt to deconstruct the art of medicine — or even to define it. In my book the art of medicine includes the science of medicine; subsumes it, if you will; but there is so much more to it. While the science of medicine might take place in the confines of a sterile laboratory or in a pharmacologic interaction within the human body, the art of medicine always takes place between at least two individuals, the clinician and the patient. Practicing the art necessitates a skill set largely learned through experience, honed with compassionate practice. It is certainly more than mere technique.

Although Stephen Bartholomew was not writing specifically about the art of medicine in this passage from Physician Assistant: A Guide to Clinical Practice, he captures its sentiment beautifully for the practicing clinician.

“It is an adventure, the journey inward, to the center of our own being, where all the dragons and all the treasures they guard really reside. The destination of such a journey is well worth the price of the adventure. With humor, with honesty, with humility, we receive as much as or more than we give, remembering:” (here he quotes Joseph Campbell in a passage from Hero with a Thousand Faces)

We have not even to risk the adventure alone, for the heroes of all time have gone before us. The labyrinth is thoroughly known. We have only to follow the thread of the hero path. And where we had thought to find an abomination, we shall find God. And where we had thought to slay another, we shall slay ourselves. And where we had thought to travel outward, we shall come to the center of our own existence. And where we had thought to be alone, we shall be with all the world.

“Sahara” © Barry H. Penchansky, M.D.

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Pilgrims in Medical Progress

In his June 27, 2012, JAMA piece, Dr. Donald Berwick tells the story of Isaiah, a troubled youth from the Roxbury section of Boston, who at the age of 15 developed acute lymphoblastic leukemia. Chemotherapy put him in remission; but as predicted, he relapsed within three years.

When Dr. Berwick held out a bone marrow transplant as the only hope for cure, Isaiah jumped at the chance. The transplant took, but also left him with diabetes and asthma.

As horrendous as that sounds, other factors in Isaiah’s life were even more difficult to overcome. He had been introduced to dope at age 5, committed armed robbery at age 12 and was addicted to crack by age 14. Two of his 5 brothers were in jail—one for murder—and a third was later killed in a drug dispute. Isaiah never finished school. His world was the street.

Eventually, Isaiah succumbed to a diabetic induced seizure, lapsed into a persistent vegetative state and died two years later. In Dr. Berwick’s words: “Cured of leukemia. Killed by hopelessness.”

In her recent article In Treatment for Leukemia, Glimpses of the Future, New York Times reporter Gina Kolata tells the story of Lukas Wartman, a young physician who developed acute lymphoblastic leukemia during his final year of medical school. Like Isaiah, chemotherapy threw Wartman into remission; like Isaiah, his cancer came back. And also like Isaiah, Wartman received a bone marrow transplant to cure his cancer. But three years later the cancer returned. This time it didn’t respond to chemotherapy and hormones.

In a last-ditch effort to save him, Wartman’s doctors sequenced his cancer’s genome, looking for clues as to what was driving the proliferation of abnormal cells. They identified an overactive FLT3 gene and discovered that it was sensitive to an existing drug. Because it was terribly expensive, Wartman’s insurance refused to pay for it; and Pfizer, the drug manufacturer, declined to provide the medication under the compassionate use program.

In the end it was Dr. Wartman’s research colleagues who chipped in to cover the cost of the medication. The treatment proved to be a success.

There you have it: one nearly universally fatal disease, two patients—each a product of circumstance and chance.

Each one received appropriate care for his condition, except in Dr. Wartman’s case a team of highly motivated colleagues banded together to go above and beyond the usual measures to insure that he received the best care possible. Even when the system refused to step up to the plate, his colleagues made sure that Dr. Wartman received the proper treatment.

In a county that boasts the best medical care in the world, accessing it might still be a problem, no matter which end of the social strata you find yourself.

But in these situations, it certainly helps to be born into the relatively well-to-do, privileged and well-connected socioeconomic class in our contemporary classless society.

The heart-berry

Thoreau tells us that the Native Americans of the eastern woodlands called the strawberry oteagh-minick. The Cree referred to it as oteimeena, while the Chippewa named it o-da-e-min. All are variants of the same word, which describe this red fruit as that resembling the heart.

“Let us not call it by the mean name of ‘strawberry’ any longer,” he writes in Wild Fruits. “[B]etter call it by the Indian name of heart-berry, for it is indeed a crimson heart which we eat at the beginning of summer to make us brave for all the rest of the year, as Nature is.”

I was pleased to learn the results of a recent study of the strawberry and its nutritional benefits. This common red berry — the first wild fruit of spring — carries substances which stimulate the production of NrF2, a protein which protects the human heart by bolstering antioxidants and helping to lower blood lipids and cholesterol.

The latest research on the heart-berry hearkens back to the Doctrine of Signatures, a 19th century idea that the shape of a plant determined its medicinal properties. For example, the tri-lobed leaf of hepatica (Hepatica nobilis) was said to be useful in treating ailments of the liver.

Now it appears as though the heart-berry might indeed be good for the human heart.

“Fragaria vesca,” Otto Wilhelm Thomé in “Flora von Deutschland, Österreich und der Schweiz 1885”

“Notes from a Healer” — Reining in the Rx

Despite a 7 percent decline in the number of overall prescriptions written for children under the age of 18 from 2002 to 2010, there was a 46 percent increase in the number of prescriptions specifically for ADHD medications for teenagers and children over the same period. When I read this disturbing statistic, Dylan came to mind.  more»

My latest installment of Notes from a Healer — Reining in the Rx — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online journal fostering discussion about the culture of medicine, medical care, and experiences of illness. Interested readers can access a list of editorial board members and regular contributors here.